The Vardell Report.Southeast Rehabilitation & Skilled Care Center

Across 6 inspections from October 2022 to July 2025, state surveyors documented 66 findings at Southeast Rehabilitation & Skilled Care Center; 66 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

6

2022–2025, standard and complaint

Findings

66

Deficiencies cited by state inspectors

Corrected

66

Of 66 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jul 312025

   Standard health inspection

   27 findings

   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level ENo actual harm, potential for moreCorrected Sep 12, 2025
   • F551Give the resident's representative the ability to exercise the resident's rights.Level DNo actual harm, potential for moreCorrected Sep 12, 2025
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Sep 12, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Sep 12, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Sep 12, 2025
   • F699Provide care or services that was trauma informed and/or culturally competent.Level DNo actual harm, potential for moreCorrected Sep 12, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Sep 12, 2025
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Sep 12, 2025
   • F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Sep 12, 2025
   • F844Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.Level CPotential for minimal harmCorrected Sep 12, 2025
   • F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level BPotential for minimal harmCorrected Sep 12, 2025
   • F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Level BPotential for minimal harmCorrected Sep 12, 2025
   • F730Observe each nurse aide's job performance and give regular training.Level BPotential for minimal harmCorrected Sep 12, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jun 42025

   Complaint investigation

   1 finding

   • F760Ensure that residents are free from significant medication errors.Level ENo actual harm, potential for moreCorrected Jun 26, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. May 72024

   Standard health inspection

   11 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jun 16, 2024
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Jun 16, 2024
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Jun 16, 2024
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level ENo actual harm, potential for moreCorrected Jun 16, 2024
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jun 16, 2024
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jun 16, 2024
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Jun 16, 2024
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jun 16, 2024
   • F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected Jun 16, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Jun 16, 2024
   • F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected Jun 16, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Mar 282024

   Complaint investigation

   2 findings

   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Apr 18, 2024
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Apr 18, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Nov 302023

   Complaint investigation

   2 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Dec 28, 2023
   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level DNo actual harm, potential for moreCorrected Dec 28, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Oct 122022

   Standard health inspection

   23 findings

   • F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Level GActual harmCorrected Oct 24, 2022
   • F610Respond appropriately to all alleged violations.Level GActual harmCorrected Oct 24, 2022
   • F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Level FNo actual harm, potential for moreCorrected Nov 1, 2022
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 1, 2022
   • F885Report COVID19 data to residents and families.Level FNo actual harm, potential for moreCorrected Nov 1, 2022
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Nov 1, 2022
   • F908Keep all essential equipment working safely.Level ENo actual harm, potential for moreCorrected Nov 21, 2022
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Nov 21, 2022
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 24, 2022
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Nov 1, 2022
   • F732Post nurse staffing information every day.Level CPotential for minimal harmCorrected Nov 1, 2022
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level BPotential for minimal harmCorrected Nov 1, 2022
   • F638Assure that each resident’s assessment is updated at least once every 3 months.Level BPotential for minimal harmCorrected Nov 1, 2022
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level BPotential for minimal harmCorrected Nov 1, 2022

   Enforcement Action

   Civil money penalty, $11,947 imposed November 30, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 12, 2022, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in October 2022, May 2024 and July 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242525F880 across all 6 inspections, oldest to newest
2. 2

   Citation F552, Cited in Two Inspections

   Inspectors cited F552 in October 2022 and May 2024. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242525F552 across all 6 inspections, oldest to newest
3. 3

   Residents Taking Their Own Medication, Cited in Two Inspections

   Inspectors cited F554 in March 2024 and May 2024. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242525F554 across all 6 inspections, oldest to newest
4. 4

   Citation F565, Cited in Two Inspections

   Inspectors cited F565 in October 2022 and July 2025. The agency describes it this way: Honor the resident's right to organize and participate in resident/family groups in the facility. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242525F565 across all 6 inspections, oldest to newest
5. 5

   Citation F607, Cited in Two Inspections

   Inspectors cited F607 in October 2022 and November 2023. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242525F607 across all 6 inspections, oldest to newest
6. 6

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in October 2022 and July 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242525F656 across all 6 inspections, oldest to newest
7. 7

   Professional Standards, Cited in Two Inspections

   Inspectors cited F658 in October 2022 and July 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242525F658 across all 6 inspections, oldest to newest
8. 8

   Significant Medication Errors, Cited in Two Inspections

   Inspectors cited F760 in June 2025 and July 2025. This citation covers whether residents are free from significant medication errors. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242525F760 across all 6 inspections, oldest to newest
9. 9

   Medical Records, Cited in Two Inspections

   Inspectors cited F842 in May 2024 and July 2025. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   222324242525F842 across all 6 inspections, oldest to newest
10. 10

    Antibiotic Use, Cited in Two Inspections

    Inspectors cited F881 in May 2024 and July 2025. This citation covers the home’s program for monitoring antibiotic use. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    222324242525F881 across all 6 inspections, oldest to newest
11. 11

    Citation F883, Cited in Two Inspections

    Inspectors cited F883 in May 2024 and July 2025. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    222324242525F883 across all 6 inspections, oldest to newest
12. 12

    Citation F887, Cited in Two Inspections

    Inspectors cited F887 in May 2024 and July 2025. The agency describes it this way: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    222324242525F887 across all 6 inspections, oldest to newest
13. 13

    Keep all essential equipment working safely, Cited in Two Inspections

    Inspectors cited F908 in October 2022 and May 2024. The agency describes it this way: Keep all essential equipment working safely. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    222324242525F908 across all 6 inspections, oldest to newest
14. 14

    Citation F921, Cited in Two Inspections

    Inspectors cited F921 in October 2022 and May 2024. The agency describes it this way: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    222324242525F921 across all 6 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in three inspections, most seriously at level F.

2. 02

   What changed after F552 was cited, and how do you check it now?

   Citation F552: cited in two inspections, most seriously at level D.

3. 03

   How do you decide whether a resident may keep and take their own medications?

   Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.

4. 04

   What changed after F565 was cited, and how do you check it now?

   Citation F565: cited in two inspections, most seriously at level E.

5. 05

   What changed after F607 was cited, and how do you check it now?

   Citation F607: cited in two inspections, most seriously at level G.

6. 06

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in two inspections, most seriously at level E.

7. 07

   How do you check that nurses and aides follow professional standards, and what happens when they do not?

   Professional Standards: cited in two inspections, most seriously at level D.

8. 08

   What happened after the medication error citation, and how are high-risk drugs double-checked?

   Significant Medication Errors: cited in two inspections, most seriously at level E.

9. 09

   How can a family request a resident’s records, and how are they kept accurate?

   Medical Records: cited in two inspections, most seriously at level E.

10. 10

    How do you track antibiotic use and decide when one is needed?

    Antibiotic Use: cited in two inspections, most seriously at level E.

11. 11

    What changed after F883 was cited, and how do you check it now?

    Citation F883: cited in two inspections, most seriously at level E.

12. 12

    What changed after F887 was cited, and how do you check it now?

    Citation F887: cited in two inspections, most seriously at level E.

13. 13

    What changed after F908 was cited, and how do you check it now?

    Keep all essential equipment working safely: cited in two inspections, most seriously at level E.

14. 14

    What changed after F921 was cited, and how do you check it now?

    Citation F921: cited in two inspections, most seriously at level E.

15. 15

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

16. 16

    What led to the 2023 fine, and has it been paid?

    An $11,947 civil money penalty was imposed November 30, 2023. CMS publishes the fine, not whether it has been paid.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Massachusetts state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Massachusetts state survey agency

  Inspection Oct 12, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Massachusetts state survey agency

  Inspection Nov 30, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Massachusetts state survey agency

  Inspection Mar 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Massachusetts state survey agency

  Inspection May 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Massachusetts state survey agency

  Inspection Jun 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Massachusetts state survey agency

  Inspection Jul 31, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 225225

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.